Form E UNIFORM MOTOR CARRIER BODILY INJURY AND …

1 Form E. UNIFORM MOTOR CARRIER BODILY INJURY AND PROPERTY. DAMAGE LIABILITY CERTIFICATE OF insurance . (Execute in Triplicate). Filed with _____ (hereinafter called Commission). (Name of Commission). This is to certify, that the _____. (Name of Company). (hereinafter called Company) of _____. (Home Office Address of Company). has issued to _____. (Name of MOTOR CARRIER ). Of _____. (Address of MOTOR CARRIER ). a policy or policies of insurance effective from _____12:01 standard time at the address of the insured stated in said policy or policies and continuing until cancelled as provided herein, which, by attachment of the UNIFORM MOTOR CARRIER BODILY INJURY and Property Damage Liability insurance Endorsement, has or have been amended to provide automobile BODILY INJURY and property damage liability insurance covering the obligations imposed upon such MOTOR CARRIER by the provisions of the MOTOR CARRIER law of the State in which the Commission has jurisdiction or regulations promulgated in accordance therewith.

2 Whenever requested, the Company agrees to furnish the Commission a duplicate original of said policy or policies and all endorsements thereon. This certificate and the endorsement described herein may not be cancelled without cancellation of the policy to which it is attached. Such cancellation may be effected by the Company or the insured giving thirty (30) days' notice in writing to the State Commission, such thirty (30) days' notice to commence to run from the date notice is actually received in the office of the Commission. Countersigned at _____. (Street Address) (City) (State) (Zip Code). This _____ day of_____, _____. _____. Authorized Company Representative insurance Company File No. _____. ( policy Number). This form determined by the National Association of Regulatory Utilities Commissioners and Promulgated pursuant to the provisions of Section 202(b)(2) of the Interstate Commerce Act (49 , Sec.)

3 302[b][2]).